Journal of Cosmetic and Laser Therapy

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Specific complications associated with non-

surgical rhinoplasty

Tuyet A. Nguyen, Shivani Reddy & Nima Gharavi

To cite this article: Tuyet A. Nguyen, Shivani Reddy & Nima Gharavi (2020) Specific complications
associated with non-surgical rhinoplasty, Journal of Cosmetic and Laser Therapy, 22:4-5, 171-173,
DOI: 10.1080/14764172.2021.1898643

To link to this article: https://doi.org/10.1080/14764172.2021.1898643

Published online: 12 Mar 2021.

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JOURNAL OF COSMETIC AND LASER THERAPY
2020, VOL. 22, NOS. 4–5, 171–173
https://doi.org/10.1080/14764172.2021.1898643

Specific complications associated with non-surgical rhinoplasty

Tuyet A. Nguyena, Shivani Reddyb, and Nima Gharavic
a
Department of Dermatology, California Skin Institute Los Angeles, Los Angeles, CA, USA; bDepartment of Dermatology, Kaiser Permanente Los
Angeles Medical Center, Los Angeles, CA, USA; cDepartment of Dermatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA

ABSTRACT ARTICLE HISTORY

Non-surgical rhinoplasty is becoming an increasingly common procedure to alter the appearance and Received 14 December 2020
cosmesis of the nose. Although rare, complications with this procedure do exist, some of which can be Accepted 1 March 2021
devastating. Major complications include infection, vascular compromise, skin necrosis, and blindness. KEYWORDS
Here we discuss the nasal anatomy, complications associated with non-surgical rhinoplasty, and techni­ Filler; hyaluronic acid; non-
ques to prevent these complications. surgical rhinoplasty

Introduction glabella which is well known for complications of vascular occlu­

sion and soft tissue necrosis.
Surgical rhinoplasty is the fourth most common cosmetic
procedure performed by plastic surgeons in the United
States. Despite its popularity, the percentage of these pro­ Common complications
cedures performed has decreased by 3% in the last year. In Reported complications of non-surgical rhinoplasty are few. In
contrast, the use of non-surgical rhinoplalsty, using soft a systematic review, Williams et al. described that the total
tissue fillers, has increased by ~1% over the same time complication rate in a series of 1600 patients was 1.63% (5).
period (1). Non-surgical rhinoplasty, which involves aug­ The most common side effects include erythema, local inflam­
mentation of the nasal contour using soft tissue fillers, has mation and swelling, and bruising which occurred at compar­
become increasingly popular over the last several years. able rates to filler placement in other anatomical sites. These
This minimally invasive technique allows patients to have complications often resolve spontaneously without sequelae.
excellent esthetic results without the high cost, anesthesia, Subcutaneous nodules, Tyndall effect, and dislocation of filler
and post-operative recovery time associated with traditional material were also noted (2,5,6). These complications are typi­
surgical rhinoplasty (2). However, the risk of complications cally associated with provider error highlighting the impor­
with non-surgical rhinoplasty still exists, particularly in tance of knowledge of facial anatomy as well as injection
patients that have undergone surgical treatment or trauma technique.
in the past. Major complications, although rare, include
vascular compromise, necrosis, and blindness. Knowledge
Uncommon complications
of nasal anatomy and injection technique is essential to
avoid these serious side effects. Infection
Infection is an uncommon and usually mild complication of
non-surgical rhinoplasty. Few cases have been reported in the
Anatomy of the nose
literature (2,6,7). All cases reported were superficial bacterial
The nose is a complex structure with a robust vascular supply infections that responded to short courses of topical or oral
(Figure 1). The nose and surrounding structures are uniquely antibiotics without sequelae (7). However, other infectious
supplied by both the internal and external carotid system etiologies including Mycobacterium have been reported with
through anastomoses between the dorsal nasal artery and the dermal fillers (8). Culture and appropriate treatment of an
angular artery. The dorsal nasal artery arises from the supratro­ infected wound is critical to prevent further complications.
chlear artery and courses over the nasal root to form anasto­
moses with the angular artery (4). Because of the anastomoses Skin and soft tissue necrosis
that occur in this area, there is an increased risk of complications Skin and soft tissue necrosis are rare but serious complications
such as the retrograde flow of intravascular filler into vital of filler injection. It is thought that necrosis from filler injec­
structures supplied by the internal carotid, including the tions can be caused by two mechanisms: 1) intravascular
ophthalmic artery, as well as increased risk of intracranial infec­ embolization through direct injection into a vessel or 2) vas­
tion. In addition, the nasal root, a common location for filler cular compromise from external pressure from the filler mate­
placement for non-surgical rhinoplasty, lies just adjacent to the rial (8). The angular, dorsal nasal, and supratrochlear arteries

CONTACT Nima Gharavi nima.gharavi@cshs.org Dermatologic Surgery & Mohs Micrographic Surgery, Department of Dermatology, Cedars-Sinai Medical
Center, 99 N La Cienega Blvd #202, Beverly Hills, CA 90211.
© 2021 Taylor & Francis Group, LLC
172 T. A. NGUYEN ET AL.

Other considerations
When performing facial fillers, it is important to under­
stand the variations in structure and vasculature from
patient to patient. However, some patients seeking non-
surgical rhinoplasty may have previously undergone trauma
or corrective surgery to the area. Previous history of surgi­
cal rhinoplasty or reconstruction can lead to distortion of
tissue and overlying vasculature (15,16). These patients may
be at higher risk for major complications with non-surgical
rhinoplasty.

Techniques to minimize risk of complications

Standard techniques to minimize complications with filler
injections regardless of anatomical location exist. Sterile
skin preparation to reduce the risk of infection and slow,
low-pressure injection techniques are crucial. In our experi­
ence, ideal antiseptics include hypochlorous acid and chlor­
Figure 1. Vascular patterns of the nose (3). hexidine wipes. Avoiding blood thinners, the use of firm
pressure, or ice packs can help alleviate more common
complications, such as erythema, ecchymoses, and swelling
are particularly vulnerable to this complication, and are all (17). If no contraindications exist, discontinuing unneces­
possible targets in the application of filler for non-surgical sary anticoagulation 2 weeks prior to the procedure may
rhinoplasty (9). The glabella is also a watershed area with help prevent these complications. For nasal filler specifi­
minimal collateral circulation and small caliber vessels making cally, injections should be performed deep to the muscu­
it susceptible to external pressure and tamponade (10). Signs of loaponeurotic layer in the preperiosteal layer for the safest
impending necrosis include severe pain, blanching, edema, and approach (18,19). Larger caliber microcannula (27 gauge or
violaceous discoloration (11–13). However, it is important to larger, in our experience) use may reduce the risk of injury
distinguish arterial from venous occlusion. While arterial or intravascular injection of filler material (18). The gla­
occlusion is often immediately accompanied by pain and bella, which is more susceptible to intravascular cannula­
blanching, venous occlusion may not present with significant tion and tamponade, can be treated with superficial dermal
pain but demonstrates venous mottling or a livedo-like phe­ injections with a serial puncture technique (19). Again, it is
nomenon (13). It is important to recognize features of impend­ crucial to understand the complex anatomy in this location
ing necrosis to allow for early intervention and prevention of paying particular attention in post-surgical patients where
further complications. anatomy may be distorted.

Vision loss Conclusion

Although rare, cases of vision loss secondary to filler injection Non-surgical rhinoplasty is becoming increasingly common
have been reported. Autologous fat injection is most com­ worldwide. It offers a fast, relatively safe, and effective option
monly associated with this complication, likely due to the fact for some patients seeking alternatives to traditional surgery.
that fat injection is often performed under general anesthesia Although rare, complications with this procedure do exist,
(at the time of liposuction), which prevents the patient from some of which can be devastating. Common complications
reporting any discomfort. However, all commonly used fillers include edema, erythema, nodules, and granuloma formation.
have been associated with reports of embolic events (14). In Major complications include infection, vascular compromise,
a literature review by Ozturk et al., the glabella was the most skin necrosis, and blindness. Extensive knowledge of nasal
common site associated with visual disturbances at 50%, fol­ anatomy and vascular supply is essential to ensure patient
lowed closely by the nose at 33.3% (9). Injection of filler for safety and prevent major complications.
non-surgical rhinoplasty poses a specific risk for this complica­
tion due to the course of the dorsal nasal artery over the nasal
root (15). The dorsal nasal artery is a distal branch of the Authors contributions
ophthalmic artery (4). Intravascular injection into the dorsal
nasal artery can cause embolization of filler material in Made substantial contributions to conception and design of the study and
a retrograde manner causing occlusion of the ophthalmic performed data analysis and interpretation: Nguyen TA, Reddy S, Gharavi N
arteries and subsequent vision loss. Clinically, this is character­
ized by instantaneous vision loss and excruciating ocular pain
Disclosure statement
(14). Treatment and reversal of this complication are rarely
successful. All authors declared that there are no conflicts of interest.
 JOURNAL OF COSMETIC AND LASER THERAPY 173

Funding Surg J. 2013 Aug;33(6):862–77. doi:10.1177/

1090820X13493638.
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disclose. protocol for prevention and treatment after use of dermal fillers.
Dermatol Surg. 2006 Feb;32(2):276–81. doi:10.1111/j.1524-
4725.2006.32052.x.
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